Intake Form General Information Name * First Name Last Name Preferred Name or nickname Date of Birth * MM DD YYYY Preferred Move-In Date MM DD YYYY Phone * Country (###) ### #### Email * SECURED INFORMATION Social Security Number * Driver's License/State ID# Military ID# Marital Status * Married Partnered Single Financial Information What is your monthly Income? * Second Form of Income Available Savings * Your Expenses * Total Monthly Expenses including, Cell Phone, Car Loans, and Others Emergency Information EMERGENCY CONTACT #1 * First Name Last Name Emergency Contact #1 Phone * Country (###) ### #### EMERGENCY CONTACT #2 Optional First Name Last Name Emergency Contact #2 Phone Country (###) ### #### Medical Information Do you have health insurance? Health Insurance ID# Do you have allergies? Yes No Anything else we should know about you? Do you have any special medical equipment? * Yes No Have you been exposed to COVID-19 in the past 5 days? * Yes No Are you currently experiencing any flu like symptoms? Cough or Fever Yes No Resident Suitability Questionnaire Can you walk independently * Yes No Sometimes Can you participate in household cleaning and chores * Yes No Sometimes Do you bathe everyday? * Yes No Sometimes Can you get dressed on your own? * YES NO SOMETIMES Do you have issues with bladder control? * YES NO Are you on probation or parole? * Yes No Do you smoke? * Yes No Are you recovering from any addiction we should be aware of? * Yes No What time do you normally go to bed? * Hour Minute Second AM PM Do you have regular medical appointments? * Yes No Do you have any food restrictions? Meat Vegetables Other List your favorite foods What activities do you enjoy? * List any concerns you may have about living with a roommate Do you work or volunteer anywhere? Please list anything else we should be aware or concerned about * I agree to all house rules and understand that violation of house rules may revoke any agreed upon rights to a bed? * YES NO Thank you! We will get back to you as soon as possible.
